Addressing Psychosocial Aspects of Atopic Dermatitis

Role of gut-derived bacterial lipopolysaccharide and peripheral TLR4 in immobilization stress-induced itch aggravation in a mouse model of atopic dermatitis

Psychological stress and intestinal leakage are key factors in atopic dermatitis (AD) recurrence and exacerbation. Here, we demonstrate the mechanism underlying bacterial translocation across intestinal epithelial barrier damaged due to stress and further aggravation of trimellitic anhydride (TMA)-induced itch, which remain unclear, in AD mice. Immobilization (IMO) stress exacerbated scratching bouts and colon histological damage, and increased serum corticosterone and lipopolysaccharide (LPS). Orally administered fluorescein isothiocyanate (FITC)-dextran and surgically injected (into the colon) Cy5.5-conjugated LPS were detected in the serum and skin after IMO stress, respectively. The relative abundance of aerobic or facultative anaerobic bacteria was increased in the colon mucus layer, and Lactobacillus murinus, E. coli, Staphylococcus nepalensis, and several strains of Bacillus sp. were isolated from the spleens and mesenteric lymph nodes. Oral antibiotics or intestinal permeability blockers, such as lubiprostone (Lu), 2,4,6-triaminopyrimidine (TAP) and ML-7, inhibited IMO stress-associated itch; however, it was reinduced through intradermal or i.p. injection of LPS without IMO stress. I.p. injection of TAK-242 (resatorvid), a TLR4 inhibitor, abrogated IMO stress-associated itch, which was also confirmed in TLR4-KO mice. IMO stress alone did not cause itch in naïve mice. IMO stress-induced itch aggravation in TMA-treated AD mice might be attributed to the translocation of gut-derived bacterial cells and LPS, which activates peripheral TLR4 signaling.

Adherence in Atopic Dermatitis

Atopic dermatitis is a chronic dermatologic condition requiring extended treatment times with topical application of medications. While atopic dermatitis treatments can be highly effective when used as directed, oftentimes patients do not respond as expected, raising concern for nonadherence versus nonresponse. This chapter aims to describe what is currently known about adherence in atopic dermatitis and to discuss strategies to improve adherence in order to improve treatment outcomes. Whether intentional or unintentional, nonadherence to treatment can limit patient outcomes of this disease for a variety of reasons. These include frustration with medication efficacy, inconvenience, and fear of side effects. Other factors include forgetfulness, financial burden of treatment, lack of trust in the physician, dislike of prescribed medication, or lack of understanding of disease or treatment. Several interventions have been studied with the aim of improving adherence in atopic dermatitis-such as educational workshops for patients and caregivers, earlier follow-up visits, and text messages reminders-however, these are often limited by sample size and power. Further research is needed to study both specific patterns of nonadherence in atopic dermatitis, as well as methods to improve them.

Stressors in Atopic Dermatitis

As with other inflammatory skin disorders, atopic dermatitis has a tendency to cause stress and also be exacerbated by it. Patients with atopic dermatitis have several disease-associated stressors, some of which include physical discomfort due to itching and altered appearance due to flare-ups. These stressors have been shown to effect patients psychosocially by altering sleep patterns, decreasing self-esteem, and interfering with interpersonal relationships. In combination with its direct effect on patients, atopic dermatitis also causes stress for parents and caregivers. Studies suggest that atopic dermatitis is strongly correlated with co-sleeping habits, which can negatively impact the health and mood of parents or caregivers. It has also been reported to interfere with the formation of a strong mother-child relationship. In order to optimize treatment for patients with atopic dermatitis, it is important to note the impact that it has on quality of life. By implementing patient counseling, sleep-targeted therapies, and the use of quality of life (QoL) indices, atopic dermatitis patients and caregivers have the potential to experience greater satisfaction with treatment.

Effects of a Psychosocial Intervention on the Subjective Experiences of Children Living with Atopic Dermatitis: A Qualitative Study in Hong Kong

Nonpharmaceutical interventions are important for addressing the psychosocial needs of children living with atopic dermatitis (AD). The current study aimed to investigate the effects of an integrative body-mind-spirit (IBMS) intervention on the subjective experiences of affected children and explore the mechanisms underlying the effects. Using a drawing-based, qualitative approach, the current study conducted two rounds of interviews with 13 children (aged 8-12 years) diagnosed with moderate or severe AD before and after they attended the IBMS intervention. Data were analyzed by using the thematic analysis method. The IBMS intervention worked by changing participants' perceptions at the cognitive level, improving their coping strategies at the behavioral level, and constructing their social support network at the environmental level. Cognitive, behavioral, and environmental factors might mediate the relationships between the IBMS intervention and participants' psychological and physical outcomes. This study highlighted the wider inclusion of child-centered qualitative research in the evaluation of the effects of psychosocial interventions designed for children.

Determinants of atopic dermatitis among children in a general out-patient clinics of a tertiary hospital in North central, Nigeria

Background

Atopic dermatitis (AD) is a chronic, inflammatory, and itchy skin condition that develops in early childhood in the majority of cases.

Aim

The objective of this study is to determine factors associated with atopic dermatitis among children aged 6 months to 14 years seen at the General Out-Patients Clinics of a tertiary hospital in north central Nigeria as well as predictors of having AD.

Patients and Methods

This was a descriptive cross-sectional study of 490 eligible children recruited using the systematic random sampling technique. The data collected were analyzed using statistical package for social sciences, version 22. Descriptive and inferential statistics was performed to determine the relationship between independent variables and having AD.

Results

The factors significantly associated with AD from this study include: male sex (χ = 4.78, P = 0.029), Being in nursery school (χ = 77.60, P = 0.000), Nupe ethnicity (χ = 49.06, P = 0.000), mothers and fathers Educational level (χ = 27.80, P = 0.000), having personal or family history of atopy (χ = 31.30, P = 0.000). After all variables that are significant was adjusted; Nursery level of education (OR = 4.076, 95% CI = 1.679-9.891, P = 0.002), Mother's Level of education (OR = 0.664, 95% CI = 0.442-0.998, P = 0.049), and personal or family history of atopy (OR = 5.585-E12, 95% CI = 5.585-E12-5.585-E12, P = 0.000) were independent predictors of AD.

Conclusion

Our data suggest that AD has a specific pattern of inheritance in children and this was predicted by: nursery level of education, mother's level of education, and family or personal history of atopy. Knowledge of this will provide a better caring strategy for predicting and preventing AD earlier in at risk children.

Sex-Based Differences in the Association between Nutrition Label Awareness and the Prevalence of Atopic Dermatitis: A Cross-Sectional Survey

Atopic dermatitis is a chronic allergic disease with multifactorial causation. Although its association with diet has been demonstrated, it remains unclear whether the prevalence of atopic dermatitis among adults is associated with nutrition label awareness. Nutrition label awareness indicates knowledge of the existence of nutrition labels on processed food, and the use of them for food selection. In this cross-sectional study, we analyzed the relationship between nutrition label awareness and the prevalence of atopic dermatitis among men and women using data from the Korean National Health and Nutrition Examination Survey VI (2013–2015), including a nationally representative sample of 13,505 Korean adults (aged > 19 years). The relationship between the prevalence of atopic dermatitis and nutrition label awareness was evaluated using t-tests, χ² tests and multivariate adjusted logistic regression analysis. Although univariate analysis showed that atopic dermatitis was associated with nutrition label awareness in both men and women, after adjustment for covariates, there was no significant association among men. The significant association between the prevalence of atopic dermatitis and nutrition label awareness among women reveals a sex-based difference in this relationship in adults, and atopic dermatitis may be managed and prevented among women by targeted education regarding nutrition labels and diet.

Role of behavioral health in management of pediatric atopic dermatitis

OBJECTIVE

To describe the behavioral components and complications in treating pediatric patients with atopic dermatitis (AD) and the critical role of behavioral health professionals in addressing disease impact and behavioral aspects of disease management for these patients and families.

DATA SOURCES

Studies and review articles were selected from medical and psychology databases for relevance to pertinent topics.

RESULTS

AD has significant negative effects in affected individuals and their families on quality of life, behavioral, emotional, and sleep disturbances, and family functioning. Effective treatment strategies for AD are available, but the challenges for children and parents in coping with disease-related concerns and in following through with the multiple aspects of treatment are considerable. A biopsychosocial model, which incorporates the interplay among biological, psychological, and social dimensions of medical care, can be implemented in various treatment settings to achieve an integrated medical and behavioral health care approach. By sharing a family orientation, using a stress and coping model, and taking into account children's developmental capabilities and concerns, medical and behavioral health care providers are equipped to bring an in-depth understanding and different evidence-based therapeutic tools to address emotional, behavioral, and interpersonal challenges imposed by moderate to severe AD in children and families.

CONCLUSION

Behavioral health and medical providers working together to provide integrated care play a critical role in helping children and families cope with the burdens imposed by AD, successfully manage the disease, and achieve optimal quality of life for affected children and their families.

Protocol for Psychosocial Interventions Based on Integrative Body-Mind-Spirit (IBMS) Model for Children with Eczema and Their Parent Caregivers

Purpose: Eczema is a pediatric skin disease that affects the psychosocial well-being of both children and their parent caregivers. This paper outlines a protocol for an experimental study that evaluates the effectiveness of a psychosocial empowerment program for children with eczema and their parent caregivers. Method: A multi-center randomized controlled trial is proposed, where parent-child dyads are randomized into two arms: an intervention group and wait-list control group. The intervention is delivered to participants in a parallel group format based on the Integrative Body-Mind-Spirit model which focuses on holistic well-being. Quality of life is measured before and after the intervention is provided, and five weeks after the intervention has been completed. Discussion: The suggested model fills a research gap in existing interventions, and provides new knowledge by evaluating the effectiveness of a tailored psychosocial intervention, delivered in group settings, for parent-child dyads affected by eczema.

Association between eczema and risk of depression: A systematic review and meta-analysis of 188,495 participants

BACKGROUND

Several studies were conducted to investigate the association between eczema and risk of depression. This was important because the care of patients with eczema might be inadequate if their psychological problems were not also recognized and treated. However, these studies had some inherent limitations such as small sample sizes or lack of controlling for potential confounders. Further, little was known about psychological co-morbidity of eczema from a global perspective.

METHODS

We conducted a systematic literature search in PubMed (1966 through January 26th 2017), Cochrane Library (the Cochrane central register of controlled trials, up to January 26th 2017), Scopus (up to December 31st 2016) and Embase (1980 through January 26th 2017) supplemented by manual searches of bibliographies and conference proceedings. The relative risk (RR) with 95% confidence interval (CI) was estimated.

RESULTS

Ten studies with a total of 188,495 patients were included. Overall, the random effects model summarizing all comparisons suggested a positive association between eczema and risk of depression, the pooled RR was 2.02 (95% confidence interval 1.76 to 2.31, I² = 33.7%). Similar results were observed in subgroup analysis by region.

LIMITATIONS

Methodological limitations such as selection biases, sample sizes, severity of other diseases, treatment strategy, age and other factors might have influenced the results.

CONCLUSIONS

Our study showed that patients with eczema were associated with an increased risk of depression. These findings implicated that clinical doctors should continue to be more aware of the association between eczema and the risk of depression.

Psychosomatic factors of atopic dermatitis exacerbation

BACKGROUND

The aim of this study was to estimate whether the stress, lack of social support, and poor emotional relationships influence the recurrence of AD in adults.

METHODS

Case-control study comprised 66 outpatients with AD and 132 controls with different skin diseases believed to be slightly influenced by psychosomatic factors. Participants were treated at the Department of Dermatology - Military Medical Academy and City Department for Skin and Venereal Diseases from January to June 2014. Stressful life events were assessed using the Paykel's Interview for Recent Life Events. The attachment relationship and perceived social support were assessed with the Experiences in Close Relationships Scale and with the Multidimensional Scale of Perceived Social Support, respectively. Univariate and multivariate logistic regression analyses were applied.

RESULTS

AD patients had significantly higher anxiety scores when initiating a close emotional relationship and when avoiding an affective attachment (OR = 1.49; CI = 1.13-1.97; P = 0.005 and OR = 1.63; CI = 1.16-2.30; P = 0.005, respectively). Perceived social support from family and friends was significantly lower among cases compared to controls (OR = 0.93; CI = 0.88-0.98; P = 0.009 and UO = 0.94; CI = 0.89-0.99; P = 0.027, respectively).

CONCLUSIONS

AD patients had higher anxiety scores, and those with low social support tended to have more frequent disease recurrence. The number of stressful life events did not differ between studied groups.

A safety review of the medications used to treat atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a common disease in children and adults which causes severe physical discomfort and psychosocial distress. Recently novel therapies for AD have been FDA approved for use which creates the need to review the safety surrounding current FDA approved AD medications.

AREAS COVERED

Published clinical studies involving topical and oral FDA approved medications for AD are included in this review. Authors used PubMed research database to search for clinical trials involving AD patients.

EXPERT OPINION

AD is a common disease which currently has limited FDA approved medications. Given the chronicity of this disease, medications are needed which control disease while minimizing side effects to allow for long term use. Newer approved medications show promise but safety data is limited given their relatively new utilization for AD.

Health-related Quality of Life and Mental Health of Adults With Atopic Dermatitis

AIM

This cross-sectional study aimed to examine the association between the prevalence of atopic dermatitis in Korean adults and their health-related quality of life and mental health.

METHODS

Data from a nationally representative sample of 11,913 adults who participated in the Korea National Health and Nutrition Examination Survey V (2010-2012) were analyzed by using SAS version 9.3.

RESULTS

The adults with atopic dermatitis had significantly lower quality of life and higher stress than did those without it. Moreover, the health-related quality of life of the adults with atopic dermatitis was significantly lower than those without the disease, after adjusting for all covariates. The adjusted odds ratios of the adults with atopic dermatitis were 1.74 (95% confidence interval [CI]: 1.14-2.65) for stress, 1.69 (95% CI: 1.00-2.84) for depression, and 1.66 (95% CI: 1.02-2.69) for suicidal ideation.

CONCLUSION

Improving our understanding of atopic dermatitis should help nurses and patients manage the stress, depression, suicidal ideation, and reduced quality of life associated with this chronic disease. There is a need to develop and conduct intervention of programs for improving mental health as well as clinical aspects of adult atopic dermatitis.

Calcipotriene/betamethasone dipropionate for the treatment of psoriasis vulgaris: an evidence-based review

While topical medications remain the cornerstone of the psoriasis treatment paradigm, they also come with the risk of multiple side effects. An alternative topical treatment option, calcipotriene or calcipotriol, is a vitamin D derivative that is thought to work by inhibiting keratinocyte proliferation and enhancing keratinocyte differentiation. Multiple studies have demonstrated its efficacy and safety in improving psoriasis when used in combination with topical corticosteroids. Given the effectiveness and side effect profile seen with this combination of topical steroid and calcipotriene, the US Food and Drug Administration approved a calcipotriene/betamethasone dipropionate product for use in psoriasis patients over the age of 12 in 2006. Our paper seeks to review clinical trial evidence of this combination medication and its use in the treatment of psoriasis vulgaris. While assessment of available evidence indicates that the topical medication is both safe and effective for the treatment of psoriasis vulgaris, addressing limitations of what is known, such as tolerability, adherence, and patient preference, of this combination drug in future high-impact studies is needed.

Analysis of Epidemiology and Risk Factors of Atopic Dermatitis in Korean Children and Adolescents from the 2010 Korean National Health and Nutrition Examination Survey

BACKGROUND

Atopic dermatitis (AD) is a common chronic inflammatory skin disease, but only few studies involved samples of children and adolescents that are representative of the entire Korean population. This study aimed to estimate the prevalence and risk factors of AD among children and adolescents in Korea by using nationally representative data.

METHODS

We used data from the fifth Korean National Health and Nutrition Examination Survey in 2010 and retrospectively evaluated 2,116 children and adolescents. Logistic regression analysis was performed to determine the relationship between AD and other variables, including IgE levels.

RESULTS

The prevalence rate of AD in children and adolescents was 15.0%. In the multivariate analysis of ages from 1 to 18 years, age (adjusted odds ratio [aOR], 0.96; p < 0.01) was related to AD. From age of 12 to 18 years, smoking (aOR, 8.99; p < 0.01) and elevated total IgE serum level (aOR, 5.31; p < 0.01) were related to AD.

CONCLUSION

Age, smoking, and elevated total IgE level were related to AD in the children and adolescents. Thus, an antismoking policy and public education are necessary for reducing the prevalence of allergic diseases. In addition, measurement of total IgE level and age may be helpful in the diagnosis of AD.

Increasing Adherence with Topical Agents for Atopic Dermatitis

Atopic dermatitis (AD) is an intensely pruritic dermatosis that develops most commonly during early infancy and childhood and may follow a chronic, relapsing course into adulthood. As a chronic disease, AD requires treatment over an extended period of time, and is therefore difficult to treat. The main difficulty stems from poor adherence to treatment by patients for reasons such as frustration with medication efficacy, inconvenience, and fear of side effects. Methods that improve adherence include creating therapeutic plans with patient preferences in mind, early follow-up visit, increasing patient education through workshops, and discussing with patients and their caretakers their fears about treatment methods. AD can be exceedingly detrimental to a patient's quality of life. Simple measures to improve adherence may improve patients' treatment outcomes and quality of life.

Association of Perceived Stress with Atopic Dermatitis in Adults: A Population-Based Study in Korea

Atopic dermatitis (AD) is a widely prevalent skin disease that affects both children and adults. The aim of the study was to assess the association of perceived stress (single-item, self-reported) with AD (self-reported) in a sample of Korean adults using a cross-sectional research design. A cross-sectional study was conducted using data from 33,018 adults aged 20 years and older collected in the 2007-2012 Korea National Health and Nutrition Examination Surveys (KNHANES). An increased level of self-reported stress was positively associated with an increased prevalence of AD in Korean adults (p for trend <0.001). After adjusting for covariates, the odds ratios (ORs) of AD among participants reporting high and very high levels of stress were 1.81 (95% confidence interval (CI): 1.22, 2.67) and 2.17 (95% CI: 1.38, 3.42), respectively, compared with those who reported low levels of stress. This study found a statistically significant association between perceived stress and AD among Korean adults.

The relationship between suicidal behaviors and atopic dermatitis in Korean adolescents

Atopic dermatitis is a common skin disease in adolescents, which may have a negative effect on the mental and emotional health. We investigated the relationship between atopic dermatitis and suicidal behaviors in Korean adolescents. Participants included 74,186 adolescents (38,221 boys and 35,965 girls) in middle and high school who completed the Eighth Korea Youth Risk Behavior Web-Based Survey. There were significant associations between atopic dermatitis and suicidal behaviors for girls. The overestimation of weight perception might have an additive impact on suicidal risk among girls. However, there were no significant associations between atopic dermatitis and suicidal behaviors in boys.

The Association between Atopic Dermatitis and Depressive Symptoms in Korean Adults: The Fifth Korea National Health and Nutrition Examination Survey, 2007-2012

Background

Atopic dermatitis (AD) is characterized by pruritic and eczematous skin lesions, which often cause depressive symptoms, anxiety, stress, sleep disturbances, social withdrawal, and stigmatization.

Methods

In total, 23,442 subjects (434 AD patients and 23,008 control subjects) aged 19 years or older and without a history of major medical illness or depressive disorders were selected from The Fifth Korea National Health and Nutrition Examination Survey 2007-2012. Following the initial selection, 2,170 age- and sex-matched control subjects were selected using 1:5 propensity score matching. Multiple logistic regression analysis was performed to identify the presence of depressive symptoms of at least 2 weeks in duration.

Results

The demographic, socioeconomic, and clinical characteristics of AD patients and control subjects were presented and compared, and some variables differed significantly between groups. Presence of depressive symptoms was set as dependent variable, and multiple logistic regression analysis was performed as follows: (1) unadjusted; (2) with alcohol use, exercise status, smoking status, and body mass index (BMI) adjusted for; and (3) with alcohol use, exercise status, smoking status, marital status, occupation, BMI, total caloric intake, history of hypertension, and history of diabetes mellitus adjusted for. Depressive symptoms were significantly higher (odds ratios, 1.46, 1.40, and 1.36; 95% confidence intervals, 1.09-1.95, 1.0.4-1.88, and 1.01-1.85, respectively) in AD patients relative to those of matched controls.

Conclusion

AD and clinical depression interact closely, and causal relationships between the two conditions have frequently been observed. Physicians should consider mental health interventions cautiously. It is particularly important that primary care physicians provide comprehensive, continuous long-term care.

Psychological Distress in Young Adult Males with Atopic Dermatitis: A Cross-Sectional Study

The relationship between atopic dermatitis (AD) and psychological distress has been well established for children and adolescents. However, it is unclear whether this relationship exists in young adults. This study aimed to assess the relationship between AD and psychological distress in young male adults in South Korea. A cross-sectional study was conducted using regional conscription data from 2008 to 2012. A dermatologist diagnosed AD based on historical and clinical features, and determined severity using the eczema area and severity index. A psychiatrist used medical records, an interview, and a psychological test to examine psychological distress (depression, anxiety, and somatization). The relationship between psychological distress and AD was assessed by multivariate logistic regression analyses. Among the 120,508 conscripts, 1517 (1.2%) presented with AD. The odds of having each type of psychological distress were significantly greater for individuals with AD compared with those without AD. The adjusted odds ratios for depression, anxiety, and somatization were 1.79 (95% CI 1.40-2.29), 1.38 (95% CI 1.08-1.76), and 1.75 (95% CI 1.40-2.20), respectively. Moderate-to-severe AD was significantly related to depression and somatization to a greater extent compared with mild AD. Depression, anxiety, and somatization are strongly and independently associated with AD in young adult males. Early treatment of skin inflammation might modify the risk of psychiatric problems. Prospective cohort studies are needed to verify causal relationships.

A Review of Multidisciplinary Interventions in Atopic Dermatitis

Multidisciplinary interventions have been developed for patients with atopic dermatitis (AD) and their families, with the aim of improving outcomes such as disease control, adherence, and quality of life. We reviewed the content of different multidisciplinary approaches to intervention for AD and evidence for their impact on key outcome measures. We also provided data from our multidisciplinary outpatient program for pediatric AD. Studies included in the review suggest benefits of multidisciplinary interventions as models of treatment or adjuncts to standard medical care, with a positive impact on outcomes including disease severity and itching/scratching. There were limitations to existing studies, including heterogeneous methods used to assess quality of life outcomes across studies and lack of controlled studies assessing the outcome of clinical care programs. Further research will be useful in assessing the impact of multidisciplinary interventions on important outcomes such as treatment adherence and sleep, identifying the elements of multidisciplinary interventions that are most critical for improved outcomes, and identifying the best candidates for multidisciplinary intervention approaches.

Knowledge, instruction and behavioural change: building a framework for effective eczema education in clinical practice

AIMS

A discussion on the reasons educational interventions about eczema, by nurses, are successful, with the subsequent development of a theoretical framework to guide nurses to become effective patient educators.

BACKGROUND

Effective child and parent education is the key to successful self-management of eczema. When diagnosed, children and parents should learn to understand the condition through clear explanations, seeing treatment demonstrations and have ongoing support to learn practical skills to control eczema. Dermatology nurses provide these services, but no one has proposed a framework of the concepts underpinning their successful eczema educational interventions.

DESIGN

A discussion paper.

DATA SOURCES

A literature search of online databases was undertaken utilizing terms 'eczema OR atopic dermatitis', 'education', 'parent', 'nurs*', 'framework', 'knowledge', motivation', in Scopus, CINAHL, Web of Science, Medline and Pubmed. Limits were English language and 2003-2013.

IMPLICATIONS FOR NURSING

The framework can inform discussion on child and parent education, provide a scaffold for future research and guide non-specialist nurses, internationally, in providing consistent patient education about eczema.

CONCLUSION

Founded on an understanding of knowledge, the framework utilizes essential elements of cognitive psychology and social cognitive theory leading to successful self-management of eczema. This framework may prove useful as a basis for future research in child and parent education, globally, in the healthcare community. A framework has been created to help nurses understand the essential elements of the learning processes at the foundation of effective child and parent education. The framework serves to explain the improved outcomes reported in previous nurse-led eczema educational interventions.

Understanding and managing atopic dermatitis in adult patients

Atopic dermatitis (AD) in adults is an important dermatologic disease. Even in patients in whom the clinical presentation is mild, the burden of disease can be considerable. Relatively little has been published on adult AD compared to the body of literature devoted to AD in children, although adults with severe AD are greatly affected by the disease. Even when AD is a mild clinical disease in adults, the psychosocial and economic burden of the disease can be profound. Patients are likely to find it useful if these nondermatologic comorbidities of AD are addressed by health care providers in clinical encounters. The treatment options for AD in adults are the same as those for children with AD, with some modifications.

Atopic dermatitis in children: management of pruritus

Children with chronic atopic dermatitis (AD)-related itch require a comprehensive treatment approach that addresses the underlying cause of pruritus, as well as symptoms and complications that extend beyond the physical domain. In small children and infants, the short-term complications of quality of life disturbance and sleep dysfunction are closely associated with the course of adolescent development. In addition, the physical damage that results from uncontrolled pruritus and scratching can lead to disease chronification. Therefore, the rapid relief of acute pruritic flares, followed by the long-term maintenance of symptom-free skin, should be prioritized in AD treatment, in an effort to avoid the emotional, social and physical chronic manifestations described above. Alleviation of AD symptoms with fourth-generation topical anti-inflammatory agents like methylprednisolone aceponate is an appropriate choice of therapy for children and infants, due to its optimized therapeutic index and versatility in formulation. Especially in AD, supplemental disease management education should be considered, to address the psycho-social needs of children (and their families) suffering from pruritus.